Does the combination of spinal manipulation with acupuncture provide better pain relief for low back pain patients?

Low back pain (LBP) is a heart sink consultation for many practitioners. Although a large proportion of patients presenting with LBP will improve within few weeks, many will continue to have pain or experience a new episode within the next year (1). One should be suspicious given the panoply of treatment options for LBP, a possible indication that most options have limited effectiveness. Therefor the recent reviews for the LBP guideline of the American College of Physicians are to be lauded, since they did not stop reviewing the evidence for treatment options, but they also evaluated the effect size of each intervention on pain and function (2,3). A change in pain or function on a scale ranging from 0 to 100 of less than 10 was considered small and from 10–20 as moderate and >20 as significant. The effectiveness of most interventions was considered being small. The effectiveness of manipulative therapy was judged to be small and of acupuncture to be moderate. Given the modest effectiveness of single interventions a combination of several treatment approaches to archive greater effectiveness seems reasonable. However, little is known on the optimal combination of different treatment options. The random selection and combination of treatments based on availability or treatment preferences of patients or health care providers is not effective and has been called supermarket approach (4). This should not be confounded with multimodal therapy approaches combining active and passive physical treatments with psychosocial and behavioral interventions for chronic LBP within a treatment concept (5). A recently published three-armed trial to evaluate the effectiveness of manipulative treatment and acupuncture combined or alone by Kizhakkeveettil et al. is highly welcome to improve guidance of clinicians which treatment options should be combined (6). To make a long story short, they did not observe any benefit from combining both treatment options compared to each alone. This might be due to the small sample size with 30 to 36 participants in each group lacking the power to detect a statistically significant difference. Another problem, limiting the generalizability of many trials in the field, might be the heterogeneity of the patients which is not captured with conventional assessment methods. I am also worried about manipulative treatment as option regardless of the presence of a diagnosed functional disorder potentially amenable to manipulation. Manipulation should be based on clinical findings (7,8). More important spinal manipulation and acupuncture can be considered as passive treatment options, where patients receive or endure an intervention. The rationale for combining two passive interventions is not obvious, given that exercise and behavioral interventions are considered most effective (2,9). Future trials assessing the combination of treatment options for LBP should rather combine active and passive treatments.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned and reviewed by the Editor-in-Chief, Zhen Xiao, MD, MPA (Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China).

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/lcm.2018.06.02). The author has no conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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